Inspection on 21/06/06 for The Chimes

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Chimes 30/07/08

The Chimes 30/07/07

The Chimes 08/11/05

The Chimes 02/12/04

The Chimes 24/06/04

The Chimes 18/04/04

The Chimes 26/03/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Chimes 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA Lead Inspector Rachel Davis Key Unannounced Inspection 21 June 2006 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Chimes Address 6 St Christopher Avenue Penkhull Stoke-on-trent Staffordshire ST4 5NA 01782 744944 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr William Molton Mrs Marilyn Molton Mr William Molton Care Home 28 Category(ies) of Dementia - over 65 years of age (2), Old age, registration, with number not falling within any other category (28), of places Physical disability over 65 years of age (3) The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: The Chimes is a large, extended detached property located in a residential area in Penkhull. The home provides care for a maximum of 28 service users; their needs may range from old age to dementia and/or physical disabilities. The home can accommodate 2 people with dementia and 3 with a physical disability, the staff are trained in this area, and the inspection process confirmed the home is able to meet individual needs. The Chimes charges its service users £359 per week, this information was accurate on 03/05/06 and recorded within the pre inspection questionnaire. The exterior and interior of the property are adequately maintained and redecoration is ongoing. The service users are offered easy access throughout the home by the use of stairs or a lift. Communal areas are spacious and comfortable; there are two lounges, which can be opened into one if required. The dining room is well maintained, sizeable and sited next to the kitchen. Small, quiet sitting areas are available on all floors. There are 26 single rooms, 12 with en-suite facilities and one double room with an ensuite. Bathrooms and toilets are appropriately situated. There are garden areas for service users and their visitors to use with the appropriate seating facilities; adequate parking is available to the rear of the property. Local amenities are within a short walking distance. Local towns are accessible by car or public transport. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over 8.5 hours by one inspector who used the National Minimum Standards for Older People as the basis for the inspection. This visit was a key inspection and therefore covered all of the core standards. The inspection included an examination of records, direct observation of care staff, discussions with service users, the manager and deputy manager, staff and visitors. The home are considering and discussing structures and systems to demonstrate recognition of diversity and the ability to meet the needs of service users. Feedback from returned questionnaires is included within this report. The inspector has made one additional visit to the home since the last inspection held in November 2005; this was undertaken on March 1st 2006. Two requirements were made as a result of that visit; the requirements from the November inspection had been met. Thirteen requirements and nine recommendations were made as a result of this visit. What the service does well: Staff within the home were committed to maintaining the best quality of care they could provide. The home can actively demonstrate its ability to meet the needs of service users with dementia and is working closely with other professionals to provide equipment and empower service users with sensory impairments. Questionnaires returned and discussions with service users and relatives confirmed they were satisfied with the staff and the care they received. All service users questionnaires confirmed they liked living at The Chimes and one service user wrote: “ The Chimes home is clean the residents are well cared for in every way with lots of TLC.” One relative wrote: The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 6 “ I have always found everything to be very satisfactory and my relative is very happy here.” The home works in partnership with other professional bodies to ensure the best outcome for the service users. Feedback received from general practitioners in contact with the care home included: “ A well managed care home” another stated, “My personal professional experience is that at the Chimes is a well lead home in which management and staff provide a caring environment, communication with the practice on resident related health matters is excellent.” The receipt, recording, storage, handling, administration and disposal of medicines were well managed and documented for the safety of the service users. The ranges of activities provided within the home were satisfactory but would benefit from ‘specialist activities’ for those service users with dementia and sensory impairments. The maintenance of the home was satisfactory and the standard of cleaning was very good. There were a variety of personal items in each bedroom and the communal areas are homely and comfortable. There is a commitment to National Vocational Qualification (NVQ) training for staff. All 4 recommendations made at the last inspection have been actioned; these are not legal requirements but are considered good practice. What has improved since the last inspection? A lot of effort had taken place to further improve the care planning processes within the home and systems had been updated. Some bedrooms had been redecorated and there is now a maintenance man working 20 hours per week for The Chimes, noticeable improvements were noted. All staff are now in receipt of an up to date moving and handling certificate. The manager confirmed contracts now confirm the room offered as required. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 standard 6 is not applicable to this home. Quality in this outcome area is “good”. This judgement has been made using available evidence, including a visit to this service. The Chimes had written information about the care home and the services provided. It was the home’s policy that prospective service users were subject to a pre-admission assessment to establish whether their needs could be met. Short stay admissions/trial visits were available for service users to “test the water” before making decisions regarding admission to the home. EVIDENCE: The Statement of Purpose and Service User Guide was not inspected on this occasion, however the last inspection found comprehensive information about the home and its terms and conditions of residency was readily available to all service users. The manager visits potential service users in their current setting and undertakes an assessment. The information gathered at assessment is transferred into the care plans. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 10 The manager or his deputy carries out an assessment to ensure that the home can meet individual needs for each service user. All 14 questionnaires received back from service users confirmed they liked living at The Chimes and felt they were well cared for, treated well, respected and able to make their own decisions. The home does not offer intermediate care facilities. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, and 10. Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The assessed health and personal care needs of service users are suitably documented and were being met, good standards of care continue. Service users were treated with respect, privacy and dignity. EVIDENCE: The home had personal care plans for service users that were relevant to their needs. These had been reviewed and updated on a monthly basis. A small random sample of service user plans was inspected. The care plans showed that a daily record was maintained for each individual. Recording systems now meet the requirements but the home must expand on the risk assessments and make sure that what is recorded is followed through. For example, one risk assessment stated ‘ hourly checks during the night required.’ there was no evidence to verify this was occurring. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 12 There was appropriate and timely referral for medical intervention. Routine medical procedures such as chiropody, dental, hearing were accessed. The inspector monitored the medication trolley and checked the medication administration record and found these to be satisfactory. There have been a number of concerns on past inspections relating to the administration of medication. This has now been fully addressed and further training has been provided to all senior staff administrating drugs. The Commission for Social Care Inspection is confident that all concerns have now been eradicated. However, the home is required to provide suitable policies and procedures for the receipt, recording, storage, handling and administration and disposal of medication, these were either out of date or not in place. Service users who self medicate (in this instance inhalers) must be risk assessed and the management of risk recorded. It was recommended that the storage of aspirin should be strengthened. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The ranges of activities provided within the home were satisfactory but would benefit from ‘specialist activities’ for those service users with dementia and sensory impairments. Family and friends were welcomed and encouraged to maintain contact with the service users in the home. Dietary needs of service users were well catered for with a balanced and nutritional selection of food available that met service user’s tastes and choices. EVIDENCE: The Commission talked about equality and diversity with the manager on this occasion. It was evident that individuals’ needs would be well researched; considerations were dealt with as the need arose, staff understood the needs of the service user group well. Further support is offered from visiting professionals and a recommendation for care staff to receive specific training for specialist need was made. Documentation to evidence equality and diversity issues should be implemented where appropriate. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 14 The Chimes provides the service users with a quarterly newsletter, this is sited on the notice board for visitors to peruse. Information within the newsletter included; new service users to the home, birthdays, obituaries, a staff fact file, a quiz and staff training qualifications. Throughout the inspection service users confirmed to the inspector that they were able to see their friends and relatives any time they wished. There was evidence to confirm that people’s spiritual and religious needs were met. Catering standards were good and all the documentation regarding and fridge freezer temperatures were seen to be up-to-date and correct. One fridge is continually running at too high a temperature, the home must address this problem. A choice of menus was available and when the inspector asked service users what they liked about living at The Chimes they all said “the food.” One service user said, “ I am fussy, there are lots of things I don’t like but they always give us an alternative both at lunch and tea time, it’s never a problem, there is always choice.” Food storage areas were tidy and suitably stocked; crockery and cutlery were of a good standard. The Commission has asked the manager to liaise with the Environmental Health Officer to confirm the salad items are suitability stored. A requirement to label and date opened jars, cold meats etc was made. A recommendation to give the kitchen area a deep clean was also made, some cupboard doors were not very clean, the cooker needed some attention and the floor needed a thorough mop. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. The home has an adult protection procedure and there is an on-going training programme in the recognition of abuse. Reasonable recording systems are in place, but more structured systems are required to ensure incidents, occurrences, complaints and other information is well documented. EVIDENCE: The service has a complaints procedure, which meets the national minimum standard; it is sited next to the visitors’ book and in the service user guide. Evidence was available to confirm that service users and others associated with the provision understand how to make a complaint. Three formal complaints have been made in the past 12 months, 1 was substantiated, and 2 were partly substantiated. There was one entry in the homes complaints log made in January 2006. Discussions with the manager confirmed that it was very unlikely that an informal complaint or grumble had not been made since then. The manager will ensure the staff are reminded to record and complete the log as necessary. The Chimes has an Adult Protection procedure and a handbook on what constitutes abuse is available for all staff. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 16 All new members of staff receive various types of training as part of their induction and this included training on how to protect residents from abuse. Discussions with the staff group confirmed they were aware of the vulnerable adults procedure and whistleblowing policy, these policies were not examined on this occasion but a requirement for the manager to review all their policies was made to ensure they are current and up to date. All the care staff have received training in the recognition of abuse, it is imperative that this training also includes the local procedures to follow. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 and 26. Quality in this outcome area is “adequate”. This judgement has been made using available evidence, including a visit to this service. Indoor and outdoor facilities at The Chimes continue to improve; in the main the home is easily accessed, cleaner than on the last inspection, bright and comfortable. The manager must undertake a Health and Safety audit throughout the home to ensure that stringent safety measures are in place, which protect the service users, staff and visitors. The current recording of risk relating the Health and Safety of the environment is “poor” as there is a significant shortfall. EVIDENCE: The home provided two lounges and a dining room, these communal areas, particularly the lounges, were clean, bright and homely. One lounge does not have a television and is considered the “quiet” lounge; the home may wish to consider offering the radio in this area. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 18 It was also noted that environmental adaptations and equipment had been provided to meet the assessed need of the service users. These included handrails fitted along the corridor and grab handles in the toilets. There was also a hoist, and assisted bathrooms for the benefit of the service users. The manager is reminded that hoists require servicing on a 6 monthly basis not annually as is presently undertaken. Generally the home is to a satisfactory standard, one toilet did not have the necessary soap, paper towels, the shower room toilet did not offer soap or towels either and one bar of hard soap was in situ, however, overall environmental standards continue to improve. Each bedroom was of a good size and it was observed that radiators were protected, a satisfactory standard of furnishings and fittings were witnessed. The laundry was inspected and found to be well organised, since the last inspection washing machines with a sluice facility have been purchased. All washing was undertaken at the correct temperatures including soiled linen in the appropriate red bags for easy identification. In most instances the home meets infection control standards, they have a policy and procedure, use soap dispensers, paper towels, protective clothing, uniforms, foot-operated bins, and have a weekly clinical waste collection. The manager needs to implement and record a number of risk assessments, it was clear that the risk assessments in place were apt and reviewed or revisited as and when required. However a number of assessments were missing, examples of these include: The use of hoists, window openings and glazing, contractors, cross infection, wheelchairs, Legionella, stress, this list is not exhaustive. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is “good”. This judgement has been made using available evidence, including a visit to this service. The home carried out robust recruitment procedures that included the taking up of references and police checks. There were sufficient trained staff with the skills mix to meet the needs of service users. EVIDENCE: An inspection of a random selection of staff files confirmed that Criminal Records Bureau Enhanced Disclosure (CRB) and Protection of Vulnerable Adults information (POVA) had been obtained for all, the Commission is satisfied that all staff have the necessary checks undertaken to ensure they are suitable to work with vulnerable people. Staff files contained all the information required by legislation recorded under Schedule 2 of the National Minimum Standards, the manager must ensure however that they can evidence an induction programme has been undertaken. All mandatory training is now provided; specialist training in sensory impairment is strongly recommended, it is imperative the staff team are offered continual professional development and are clear on how to understand and value service users with more complex requirements. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 20 The manger has introduced a training matrix, which enables him to keep track of when, and what training is required. The Commission can confirm that 54 of staff are in receipt of a National Vocational Qualification. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 3, 35 and 38. Quality in this outcome area is “poor”. This judgement has been made using available evidence, including a visit to this service. An experienced manager (who is also the proprietor) manages the home and good working relationships between all parties were observed. Health and safety risk assessments need to be added to and strengthened ensuring that the service users and staff are as safe as is reasonably practicable. The lack of fire risk assessment and the lack of evidence to support safe evacuation procedures do not meet required standards. EVIDENCE: Service users were very satisfied with the home comments made included: “ Bill is a real comedian, he soon gets us laughing” The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 22 “ I like it here, I can do as I please” “Bill and the staff are very nice” The manager has achieved the Registered Mangers Award, this is the qualification required (or its equivalent) by the Commission for all managers of a care service. Bill has worked hard to improve the homes care practices but there needs to be more evidence to confirm that he consults with service users and their families about individuals care needs, interests and preferences. The manager ensures the service users control their own money except where they choose not to. The records of financial involvement were not examined on this occasion. Fire risk assessments were in need of completion for all service users, presently only an audit is in place. The manager is also aware that he must complete a written contingency plan in the event of a fire or bomb threat regarding safe placement of service users. The registered manager ensures that all maintenance work, repairs, annual checks, mandatory training, testing of equipment and regular fire drills are undertaken. The majority of records checked were up to date and met with the requirements. However, the fire alarm had not been tested since May 3rd and emergency lighting must be checked monthly, this was presently been done on a three monthly basis. The Commission has made a requirement for the manager to ascertain if he is meeting the legal obligations relating to Legionella testing. The accident book was scrutinised on this occasion, it was verified that two recent accidents, one resulting in a visit to hospital, had not been recorded, this lack of recording is unacceptable and the Commission discussed this misdemeanour at length with the manager. It was also clear that records were not recorded in a manner that meets with DATA Protection; again this was highlighted to the manager. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X 2 X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The registered person must ensure that the medication policy meets with the homes practice, this is not currently so. A risk assessment and agreement referring to selfmedication must be in place. The registered person must ensure that all bathrooms and toilets are provided with liquid soap and paper towels unless a risk assessment proves otherwise. The registered person must confirm with the appropriate person his responsibilities with regard to the testing for Legionella. The fridge temperature must be reduced in one fridge it is currently running at 10 degrees Celsius. The registered person must ensure that opened jars, cold meats etc are labelled and dated. The registered person must ensure the fire alarms are tested weekly and emergency lighting DS0000008211.V300249.R01.S.doc Timescale for action 21/07/06 2 3 OP9 OP21 13(4)(b) 13(3) 01/07/06 01/07/06 4 OP26 13(3) 21/07/06 5 OP26 13(3) 21/07/06 6 OP26 13(3) 28/06/06 7 OP38 23(4)(c) (iv) 28/06/06 The Chimes Version 5.2 Page 25 8 OP38 9 OP38 10 11 12 OP38 OP38 OP38 13 OP38 monthly The registered person must audit the homes policies and procedures to ensure they meet with practice. 13(4)(b) The registered person must ensure bath and manual hoists are serviced on a 6 monthly basis. 12(1) The registered person must ensure the storage of records complies with DATA Protection 17(2) The registered person must ensure all accidents are suitably recorded. 13(4)(a) The registered person must ensure that all risk assessments required are in place for the building 24(4)(c)(ii A thorough and robust risk i) assessment must be in place for each service user referring to the evacuation process, individual need etc. The responsible individual must also complete a contingency plan in the event of a fire or bomb threat regarding safe placement of service users. 12(1)(a) 01/09/06 21/07/06 01/07/06 28/06/06 21/08/06 21/09/06 The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 8 9 Refer to Standard OP9 OP12 OP12 OP18 OP19 OP30 OP33 OP38 OP38 Good Practice Recommendations The registered person should consider measures to ensure that aspirin storage is individualised and also be able to account that it is dispensed to an individual service user. The registered person should consider a more structured and individualised approach to the homes activities programme. The registered person should consider offering service users further opportunities in training opportunities and the running of the home. The registered person must ensure that the recognition of abuse training includes the local procedures to follow. It is strongly recommended that the registered person arrange a deep clean of the kitchen. It is strongly recommended that the registered person offer staff training in sensory impairment. The registered person should reflect on ways in which to evidence that equality and diversity are both considered and met. The registered person should further promote the need for visitors to sign in and out of the establishment. The registered person should consider dating policies to assist with the reviewing process. The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI The Chimes DS0000008211.V300249.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!